5/11/2014€¦ · · 2014-05-125/11/2014 1 dror paley, md paley advanced ... 5/11/2014 15...

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DROR PALEY, MD

Paley Advanced

Limb Lengthening Institute

St. Mary’s Hospital

901 45th St.

West Palm Beach, Florida 33407

www.PaleyInstitute.org

Paley Institute

Disclosure

• I am a consultant to Ellipse Technologies

• I receive royalties from SN Orthopedics and

Pega Medical and Springer

Congenital Femoral

Deficiency (CFD)

• Formerly called PFFD (proximal femoral focal

deficiency

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CFD


deficiency

• Occurs 1:40,000 births

CFD


deficiency


• Cause unknown

• Most are not hereditary

CFD


deficiency


• Cause unknown


• May be associated with Fibular Hemimelia

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CFD


deficiency


• Cause unknown


• May be associated with Fibular Hemimelia

• If bilateral or more than one limb affected

may be hereditary or related to virus, drugs,

radiation, syndrome

Classification of CFD

• Paley Classification created in 1996

• Now used by most pediatric orthopedic

surgeons

• Paley Type determines treatment

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Steps

• Step 1: determine Paley type

• Step 2: predict limb length discrepancy (LLD)

at skeletal maturity using Multiplier method

Paley et al, JBJS 2000

Paley Growth iPhone App

FREE

Steps




• Step 3: work out length correction strategy

• Pelvic Osteotomy or Superhip 1cm

• Lengthening 1 5-8cm



• Growth plate closure(epiphysiodesis) 5cm

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Steps



at skeletal maturity using Paley Multiplier

method


• Step 4: outline reconstructive life plan

Planned age for each procedure

Reconstructive Life Plan

Surgery Length Gain

1. Pelvic Osteotomy or Superhip 1cm

2. Lengthening 1 5-8 cm



5. Growth plate closure(epiphysiodesis) 5 cm

6. Hemi-epiphysiodesis (PRN)

Total 15-30 cm 6-12 in

Customized Treatment

for Each Patient





• Step 4: outline reconstructive life plan

All determined at the first consultation visit

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External Fixation Time

• Distraction Phase (lengthening time)

External Fixation Time

• Distraction Phase (lengthening time)

• Consolidation Phase (bone healing time)

Rule of Thumb 1

• Total Ex Fix time = 1month for each cm.

e.g. 5cm lengthening = 5 months with ex fix

e.g. 8cm lengthening = 8 months with ex fix

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Rule of Thumb 2

• Distraction Time = Consolidation Time

• Distraction + Consolidation Times

=Total Ex Fix time

e.g. 8cm lengthening = 8months Ex Fix time

Distraction time = 4months

Consolidation time = 4 months

Soft Tissue Releases

It is important to lengthen key

muscles and tendons during

surgery!

This prevents damage to muscles,

joints and growth from limb

lengthening

Physical Therapy

1-2 hrs/day

Must maintain 45°

or more of knee flexion

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Botox Injection

Quads: 10u/kg body wt.

prevents muscle spasm & pain during PT

Post-op Course

• 3 days in hospital

• Start lengthening on day 7 at 1mm/day

• Followup every two weeks

• Slow lengthening rate if knee motion

decreases

• Stop lengthening if knee motion <45°

The External Fixator Used must have Knee Hinges

to protect knee from pressure and dislocation during limb lengthening

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Specialized Physical Therapy is Critical to the Process

• Passive stretching of knee to 90°

• Passive abduction of hip

• Strengthening of hip abductors

• Strengthening of quads

• Other special limb lengthening

exercises

At the Paley Institute we prefer to start lengthening

between ages 2-4 years old

Preparatory Surgery

• Before lengthening assess for hip and knee

instability, contractures, & deformities

• If present then perform surgery to correct

these before lengthening

• This is called PREPARATORY SURGERY

which can start as early as age 2

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Two year old boy with CFD type 1b:

about to undergo Preparatory Hip & Knee Surgery

Problems of knee and hip deformities

have to be resolved before lengthening

Dec 9, 2009

Preparatory Surgeries:

Superhip and Superknee procedures (see part 2)

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Jan 4, 2010

1st Lengthening

Feb 1, 2010 March 8, 2010

Lengthening Fixator with Hinge across the Knee Joint

which allows Knee Motion Exercises

After 8 cm lengthening

April 14, 2010

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April, 2010

July 12, 2010

Removal of Fixator with Rodding to prevent Fracture

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Long Term Experience and Results

The next two patients (one boy and one girl)

have CFD treated during CHILDHOOD by Dr. Paley

They both had Lengthening Reconstruction Surgery

They are now both young ADULTS

They now have EQUAL LEG LENGTH.

Boy CFD 1a Girl CFD 1a

Hip Instability/Dysplasia

is Treated by Pelvic

Osteotomy

Dega

This prevents the hip from dislocating out of joint

during lengthening of the femur

CFD/PFFD

severe deformity

type 1b

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CFD/PFFD

severe deformity

type 1b

Patho-anatomy of Femur

• Proximal femur is flexed 90° and internally rotated

45°

• Distal femur is externally rotated

• If proximal femur is cartilaginous junction is bone to

cartilage (neck type)

• If proximal femur is ossified, junction is cartilagenous

(subtrochanteric type)

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After Superhip & Superknee Procedures

CFD/PFFD

severe deformity

“SUPER HIP” Procedure

First Superhip by Paley 1997

Super Hip Procedure

• Extra-articular soft tissue releases to correct:

flexion, abduction and ext. rotation

CONTRACTURES of HIP JOINT

• Special subtrochanteric osteotomy to correct:

varus, flexion and ext. rotation

BONY DEFORMITIES of the FEMUR

• Pelvic osteotomy to correct lack of femoral head coverage ACETABULAR DYSPLASIA

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After Superhip Procedure

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Before Superhip After Superhip

femoral neck deformed

& not ossified femoral neck no deformity

& ossified

Sept 21, 2009

Age 4: LLD =11cm

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Oct 5, 2009

First Lengthening Age 4

osteotomy

Oct 28, 2009

First Lengthening

Dec 8, 2009

Goal of Lengthening Achieved: 8cm = 3 ¼” LLD = 3cm

Jan 15, 2010

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During Lengthening in Physical Therapy

May 20, 2010

Last X-rays before removal of fixator

Removal and rodding of femur: 8months after surgery

June 14, 2010

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Six Months after removal: LLD = 3 cm

June 14, 2010

Conclusion

Each type of CFD has its own

treatment

Paley classification determines the

type of treatment

Follow a Reconstructive Life Plan

Specialized Centers are best equipped

to treat CFD

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UNSATISFACTORY RESULTS after

Lengthening for Fibular Hemimelia are due to:

RECURRENT or RESIDUAL

foot deformities

Naudie et al., JBJS 79B 1997

Choi et al., JBJS 72A 1990

100% 50% 10%

Recurrence of Foot Deformity

Paley et al study 1999

Superankle Procedure

Soft tissue releases combined with

Osteotomy of Supramalleolar and/or

Subtalar Coalition

First procedure to prevent recurrence

of foot deformity and to give a stable

ankle

Developed by Paley in 1996

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Ankle joint maloriented

+

diaphyseal procurvatum

anlage

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augmentation

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Os calcis laterally translated to talus

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Type 3b FH: 18-month-old pre-op Post lengthening and STO

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Post-op: age 3 years

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2006: knock kneed

2008: knee straight

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Jan 10, 2011

Removal of Ex Fix (6months postop) 3rd Lengthening age 14: Femur and Tibia

Age 16 : Equal leg length

No pain, plays soccer

Recommendations

1. Type 3: Superankle: STR (complete analge

resection) + SM and/or ST osteotomy +

lengthening

2. Serial Staged Lengthenings

± epiphysiodesis

3. Ankle arthrodesis if cannot

otherwise stabilize ankle

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Recurrent Foot Deformities

• <10% following

superankle procedure (STR + Osteotomy)

• In these 10% the foot deformity can be

corrected with the 2nd staged lengthening

Why amputate a childs foot

Our worst cases (<10%)

are like a painless, plantigrade ankle arthrodesis

Worst case analysis is:

painless plantigrade stiff foot or ankle arthrodesis

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Deformity Correction in Adults:

Fixator-Assisted Nailing (FAN)

and

Fixator-Assisted Locked Plating

(FALP)

John E. Herzenberg, MD, FRCSC

Clinical Professor, Orthopedic Surgery, University of Maryland

Director, International Center for Limb Lengthening

Sinai Hospital - Baltimore, Maryland USA

VuMedi Seminar May 5th, 2014

Advanced Limb Reconstruction Techniques

Disclosures:

Unpaid consultant for Smith+Nephew,

Orthofix, Ellipse.

Support for “Baltimore Limb

Deformity Course” from

Smith+Nephew, Orthofix, Ellipse.

External fixation for

deformity correction:

Accurate, but is it

comfortable?

2

Internal fixation done poorly Internal fixation done well

Fixator Assisted Internal Fixation:

The accuracy of external fixation

AND the patient convenience of

internal fixation.

(Best of both worlds)

Options: Nails, Plates

Fixator Assisted Nailing

Nailing (FAN)

Fixator

Assisted Plating

(FAP)

3

t = amount of translation needed

Intra-operative x-ray confirms correction prior to fixation

Reamings

6

Blocking Screws

7

Fixator-Assisted Nailing

(FAN)

• Advantages: • Accurate correction

• Patient never sees

fixator

• Disadvantages:

• Technically challenging

• Not widely done

How to make this technique

easier for of the surgeon?

Fixator Assisted Locked Plating

(FALP)

LDFA 86°

MPTA 104°

20° valgus

Lateral MAD 15° procurvatum

8

Trapezoidal wedge resection

9

Trapezoid wedge resection to shorten bone

Temporary stabilization with simple external fixators.

Alignment check with image intensifier and grid.

10

Pre-operative Follow-up

13

19 y.o.

woman

Genu

Valgum

84

91

15

Cautery Cord Test

Plate does not have to touch the bone!

16

Take home message:

1. Fixator Assisted Nailing (FAN)

is technically demanding

2. Fixator Assisted Plating is

relatively easy.

3. FAP allows accurate correction

and patient comfort (no long

term external fixator)

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Correction of Nonunions and

Malunions

Trevor M. Owen, M.D.

Assistant Professor – VTC School of Medicine

May 12, 2013

Disclosure

• Nothing to disclose

Disclaimer

• Plates, Screws, Rods, & Wires are the

mainstay of my practice.

• External fixation is widely applicable but

should be used only in appropriate cases.

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Overview

• Nonunion

• Workup

• Management

• Malunion

• Management

Nonunion Workup

• Why did the nonunion develop?

• Failure of mechanics

• Failure of biology

Nonunion Workup

• Radiographs

• Hypertrophic

• Oligotrophic

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Nonunion Workup

• Laboratory Studies

• Infection Panel

• WBC, ESR, CRP

Nonunion Workup


• Infection Panel

• WBC, ESR, CRP

• Endocrine Workup

• Vitamin D

• Calcium

• PTH

• TSH

• Testosterone

Nonunion Workup


• Infection Panel

• WBC, ESR, CRP


• Vitamin D

• Calcium

• PTH

• TSH

• Testosterone

Plan For Staged Reconstruction

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Nonunion Workup


• Infection Panel

• WBC, ESR, CRP


• Vitamin D

• Calcium

• PTH

• TSH

• Testosterone

50,000 Units Vit D Weekly


Nonunion Workup


• Infection Panel

• WBC, ESR, CRP


• Vitamin D

• Calcium

• PTH

• TSH

• Testosterone

50,000 Units Vit D Weekly

Endocrine Consult


Nonunion Management

• Correct all modifiable biologic factors

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Nonunion Management

• Correct all modifiable biologic factors

Nonunion Management

• Biopsy all nonunions at the time of surgery

Nonunion Management

• Biopsy all nonunions at the time of surgery

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Nonunion Management

• Non-infected, Aligned

• Non-infected, Mal-aligned

• Infected, Aligned

• Infected, Mal-aligned

Nonunion Management


• Reamed Exchange Nailing

• Compression Plating

• Bone Grafting

Nonunion Management


• Reamed Exchange Nailing

• Compression Plating

• Bone Grafting

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Nonunion Management


• Stiff

• Takedown of nonunion with revision fixation

• Gradual correction and compression with external

fixator

• Mobile

• Acute correction with internal fixation

Nonunion Management


Nonunion Management


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Nonunion Management


Nonunion Management


Nonunion Management


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Nonunion Management


Nonunion Management


Nonunion Management

• Infected, Aligned & Infected, Mal-aligned

• Staged Reconstruction

• Stage 1

• Extensive debridement with spacer placement

• Cast Immobilization vs External Fiation

• Appropriate IV antibiotics x 6 weeks

• Stage 2

• Reconstruction with internal fixation versus external

fixation

• Bone grafting

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Nonunion Management


Nonunion Management


Nonunion Management


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Malunion Management

Malunion Management

• Acute Correction

• Amenable soft tissues

• Acceptable shortening

• Gradual Correction

Malunion Management


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Malunion Management



Malunion Management


Malunion Management

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Malunion Management

Malunion Management


Malunion Management


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Malunion Management


Malunion Management


Malunion Management


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Malunion Management


Malunion Management


Malunion Management


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Malunion Management


Malunion Management

Malunion Management

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Malunion Management

Thank You

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S. Robert Rozbruch, MD Chief, Limb Lengthening & Complex Reconstruction Service

Professor of Clinical Orthopedic Surgery

External Fixation

IntegratedFixation • LON= lengthening

over nail

• LATN= lengthening

and then nailing

• LAP= lengthening and

then plating

• BTON= bone transport

over a nail

Internal lengthening

nail

Lengthening over

nail (LON)

Lengthening and

then plating (LAP)

Lengthening and

then Nailing (LATN)

Bone transport over

a nail (BTON)

Pros

• Decreased time in

external fixation

Cons

• 2 surgeries

• Still wear ex fix

http://www.hss.edu/index.htm

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Lengthening

Over an

Existing

IMN

LLD 3 cm

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CUT BONE AROUND EXISTING IM NAIL

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2.5

mo

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No contact between IM nail

And External Fixation

4 cm LLD

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Failed TAR and LLD

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7 cm

Out of frame in 6 months

Decrease time in frame

Prevent refracture of

regenerate

Correct periarticular

deformity

Osteotomy distal femur or

proximal tibia

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LLD = 4.5 cm

25 y/o male

Congenital LLD

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External Fixation

IntegratedFixation • LON= lengthening

over nail

• LATN= lengthening

and then nailing

• LAP= lengthening and

then plating

• BTON= bone transport

over a nail

Internal lengthening

nail

www.hss.edu/limblengthening

5/11/2014€¦ · · 2014-05-125/11/2014 1 dror paley, md paley advanced ... 5/11/2014 15...

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